Provider Demographics
NPI:1154634889
Name:FULL, JESSECA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSECA
Middle Name:LYNN
Last Name:FULL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 24A
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-9767
Mailing Address - Country:US
Mailing Address - Phone:304-275-3889
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1050
Practice Address - Country:US
Practice Address - Phone:304-927-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA 001094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant